Intravenous Abuse Research Articles

Complications Relating to Intravenous Buprenorphine Abuse: A Single Institution Case Series

We present a retrospective descriptive study of cases admitted to Tan Tock Seng Hospital from March 2005 to October 2005 with complications of Subutex abuse. A total of 8 patients were studied. Of the 8, 7 were male and one was female. Their complications consist of the following: arterial pseudoaneurysm (2), arterial pseudoaneurysm with infective venous thrombus (1), infective venous thrombus (1), venous thrombus (2), end arterial spasms (1) and sympathetic dystrophy (1). For the patient who presented with buprenorphine-associated neuropathy, non-operative treatment with analgesics was given. Conservative medical therapy involving deep venous thrombosis treatment was instituted for the patient with deep venous thrombosis. Repair, restorative bypass and embolectomy surgery were performed for patients who had severe embolic/thrombotic complications. One of the patients who received the above surgery required amputation of his lower limb. Of the 8 patients, 4 were treated medically, 3 required surgery and 1 required amputation. Their recoveries were uneventful. Of the 8, 1 absconded and was not followed up with. Parenteral injection of buprenorphine can cause a wide range of vascular complications from simple vascular irritation to severe infective thrombosis and pseudoaneurysms requiring limb amputations. Non-sterile preparation of an injected substance or non-sterile injection sites and the repeated punctures of major vessels are possible culprits in those who are seen to have acute infection of injection sites.

Endocarditis due to Neisseria subflava biovar perflava

Clinical Case The subject was a 30-year-old male addict with a history of intravenous substance abuse. In 2002, he had infectious endocarditis caused by methicillin-resistant Staphylococcus aureus, which displayed a good response to antibiotic treatment. In April 2003, he suffered a motor vehicle accident that produced a femoral fracture requiring the insertion of an intramedullary spike. A week before hospitalization, he showed symptoms of general weakness, fever, and chills, and during an examination, a 2 to 3/6 systolic murmur was detected. Because of the physical results and his previous history, which included tricuspid valve endocarditis, infectious endocarditis was suspected. Blood was drawn for culture and treatment was started empirically with 500 mg of vancomycin plus 400 mg of ciprofloxacin i.v. twice a day. A transthoracic echocardiogram showed normal movement of the intraventricular septum but a lack of movement in the medial and apical septa, with a slight deterioration of systolic function and no vegetative growths. It also showed an irregular surface on the tricuspid valve, a serious level of insufficiency, and dilated right-side cavities. Initial laboratory results were as follows: erythrocyte sedimentation rate, 52 mm/h, and white blood cell count, 9,400/mm. The HIV serology was negative. Despite antibiotic treatment, after 1 week of hospitalization, the patient was still febrile with chills. A week from the date of hospitalization, a transesophageal echocardiogram showed a rounded and irregularly edged vegetative growth with a small pedicle on the left auricle, over the interauricular septum. Diagnosis was a suspected rupture of the interauricular septum and moderate tricuspid failure. Because of the persistence of fever and the fact that the patient had a compromised immune system and a history of hospitalization, ciprofloxacin was replaced with 500 mg of imipenem every 6 h in addition to the twice-daily dose of 500 mg of vancomycin. After a clear and rapid clinical recovery, the patient again became febrile. In four blood culture samples (Laboratorios Britania, Argentina), processed by a standard methodology, gram-negative diplococci were observed, which after 24 h of cultivation on blood agar, developed into small, regular, convex, and

Aluminum Toxicity Due to Intravenous Injection of Boiled Methadone

To the Editor: A 42-year-old man who was in rehabilitation for intravenous substance abuse presented with a three-month history of seizures and incoordination. Other symptoms included dysarthria, a hesitant pattern of speech, myoclonic jerks, postural tremor, emotional lability, and fluctuating short-term memory. On questioning he admitted that for four years he had been concentrating his methadone preparation, which was diluted with a grape-flavored drink, by heating it in an uncoated aluminum pot. He would then reconstitute the residue for intravenous injection. His serum aluminum level was 6650 nmol per liter (reference interval, <400). The patient reported that he did not . . .

Plexopathy in a Heroin Addict

Muscle and peripheral nerve disorders are important complications in intravenous heroin abusers. Rhabdomyolysis and acute lumbosacral plexopathy are important in the differential diagnosis of patients developing muscle weakness in an intensive care unit after intravenous overdoses of heroin. A 25-year-old man developed rhabdomyolysis with neuromuscular involvement, and consistent clinical and electrodiagnostic features of lumbar plexus neuropathy after an intravenous injection of heroin. The improvement occured slowly, over months, in spite of intensive physiotherapy.

Chronic Aluminum Toxicity Due to Intravenous Substance Abuse Managed with Deferoxamine Chelation Therapy: Case Report.

Aluminum toxicity first came to attention in the medical literature as a sequela of peritoneal or hemodialysis, where accumulation of aluminum in body tissues results from the use of aluminum-containing dialysate and phosphate binders. The most common clinical presentations of aluminum toxicity include anemia, bone disease, and a syndrome of encephalopathy known as the dialysis encephalopathy sydrome (DES). We present the unique case of a 42-year-old man who developed chronic aluminum toxicity from the intravenous injection of a methadone preparation intended for oral consumption. The methadone solution was concentrated for intravenous injection by heating in aluminum cookware. Experiments performed in our laboratory reproducing this technique, using weakly acidic solutions similar to popular drink mixes, confirmed that significant amounts of elemental aluminum can be leached from aluminum cookware when heated. The patient presented to medical attention with generalized seizures, profound cerebellar dysfunction, myoclonus, and speech apraxia, all of which are characteristic of DES. The peripheral blood film revealed bizarre red cell morphology, with clear features of iron deficiency and prominent coarse basophilic stippling, suggesting impaired iron utilization, which is at least one mechanism of aluminum related hematologic toxicity. A bone marrow biopsy demonstrated extensive osteosclerosis and myelosclerosis, compatible with significant metabolic bone disease. Subsequent investigations revealed a serum aluminum level of 7200 nmol/L, eighteen times the upper limit of normal (400 nmol/L). Chelation therapy with a continuous intravenous infusion of deferoxamine was started, and over a course of ten months the serum aluminum level was reduced to 2390 nmol/L with few side effects. The patient made a significant neurologic recovery and returned to life in the community. This is the first detailed account of the successful use of deferoxamine to chelate aluminum in a patient without dialysis-dependent renal insufficiency. This case also highlights heavy metal exposure as a diagnostic consideration in intravenous substance abusers presenting with multiorgan dysfunction, and the importance of performing a thorough inquiry into injection drug practices when evaluating these patients.

A Case of Rhabdomyolysis After Intravenous Heroin Use

A Case of Rhabdomyolysis After Intravenous Heroin Use

Multi-drug-resistant tuberculosis in a Department of Infectious Diseases

In Western Europe, Portugal has the highest incidence of tuberculosis (TB) as well as HIV infection. At the Department of Infectious Diseases, Hospital de Santa Maria, Lisbon, we have observed a steady increase in cases of drug resistant (DR) and multi-drug resistant (MDR) TB over the last few years. To identify the determinants of drug- resistant tuberculosis, clinical notes from all patients admitted to the Department of Infectious Diseases from 1995 to 2000, with DR- or MDR-TB were retrospectively reviewed. A total of 212 samples, from 190 patients with tuberculosis were tested for sensitivity to first line anti-TB drugs, using standard methods. Most patients (61%) were intravenous drugs users. Resistance to at least one drug was found in 44 patients (23%); notes were available for review in 39 (36 HIV infected) patients. The rate of DR-TB was 9% (n=16) and that of MDR-TB was 15% (n=28). Almost half of the MDR-TB cases (n=13) showed resistance to four drugs (HRSE). Thirteen patients (69%) were first diagnosed as fully sensitive tuberculosis, during their first admission to the Department; however, later on they developed MDR-TB or DR-TB. Non-compliance with therapy and the intravenous use of drugs were associated with MDR-TB. The large increase in MDR-TB in our Department is of great concern. The clustering of identical resistance patterns suggest transmission of TB from a single source patient that may well have occurred in a nosocomial context. Traditional tuberculosis control measures seem to be insufficient in settings were prevalence of HIV infection and tuberculosis are high. This becomes even more important when the incidence of intravenous substance abuse, and often non-compliance, are predominant factors. Appropriate isolation facilities for all suspected tuberculosis cases as well as rapid diagnostic and drug susceptibility tests will be required to prevent further spread of MDR-TB.

Prevalence of psychiatric and substance use disorders in opioid abusers in a community syringe exchange program

The present study evaluates the prevalence of psychiatric and substance use disorders in male and female intravenous opioid abusers participating at a community needle exchange program (NEP). All participants ( n=422) were administered the Structured Clinical Interview for the DSM-IV (SCID) for Axis I disorders and antisocial personality disorder (APD). Psychiatric and substance abuse comorbidity were highly prevalent. Major depression was the most common current and lifetime Axis I non-substance use disorder (6 and 21% of the sample, respectively); 37% were diagnosed with APD. Over 50% of the sample was diagnosed with at least one non-substance use Axis I disorder or APD. In addition to opioid dependence, cocaine dependence was the most prevalent current and lifetime substance use disorder (68 and 78% of the sample, respectively), followed by alcohol and cannabis dependence. Overall, participants reported a mean of over one current and over three lifetime substance use disorders in addition to opioid dependence. Women reported higher rates of post-traumatic stress disorder (PTSD), while men were more likely diagnosed with APD. Presence of a psychiatric disorder was associated with increased prevalence of substance use disorder for all drug classes. The high rates of comorbidity observed in this sample suggest that the harm reduction efforts of NEPs can be significantly enhanced through referral of participants to programs that treat substance use and/or other psychiatric disorders.

Interaction between HIV and intravenous heroin abuse?

In this article I will review the findings of the potential interactive effects of HIV infection and heroin use as observed in both clinical and laboratory studies. Some of the findings are discrepant and I will endeavour to propose models that could accomodate these variant results as well as suggest factors that could be considered in analysing future investigations in order to resolve these apparent discrepancies.

P261 Dilated cardiomyopathy secondary to chronic intravenous amphetamine abuse

P261 Dilated cardiomyopathy secondary to chronic intravenous amphetamine abuse

Intravenous and non-intravenous cocaine abusers admitted to inpatient detoxification treatment: a 3-year medical-chart review of patient characteristics and predictors of treatment re-admission

This naturalistic study examined the admissions and re-admissions of 341 intravenous (IV) and non-IV cocaine abusers over a 3-year period to an inpatient, hospital-based drug-and-alcohol detoxification treatment program. IV cocaine abusers reported higher rates of residential instability, unemployment, Hepatitis C, HIV and cirrhosis than non-IV cocaine abusers. In addition, IV cocaine abusers were administered more medical evaluative tests during treatment and accessed inpatient detoxification treatment more often during the 3-year study period. A Cox regression model demonstrated that residential instability and IV route of cocaine administration were significant predictors of inpatient detoxification re-admission. In light of the important differences between IV and non-IV cocaine-abusing groups, detoxification services should view route of cocaine administration as a key topic in treatment delivery and residential stability as an important topic in the discharge-and-referral process.

Free radicals mediate amphetamine-induced acute pulmonary edema in isolated rat lung

Intravenous amphetamine abuse may cause serious cardiopulmonary complications via unknown mechanisms. We investigated the role of free radicals in the amphetamine-induced lung injury using isolated rat lungs. Adding amphetamine into the perfusate caused dose-dependent increases in perfusion pressure and lung weight. Amphetamine increased the filtration coefficient (K f) by 90 ± 20% and 210 ± 10% at doses of 10 μM and 50 μM, respectively, as compared to the baseline level. Pretreatment with dimethylthiourea (DMTU), an oxygen radical scavenger, abolished the pulmonary hypertension, lung weight gain, and permeability changes. We also examined the effect of amphetamine on free radical generation in polymorphonuclear leukocytes (PMN). Adding phorbol myristate acetate (PMA, 1 nM) enhanced the chemiluminescence indicating the functional viability of the isolated PMN. Amphetamine (50 μM) significantly enhanced the chemiluminescence generation of PMN by 152 ± 26% as compared with the baseline value. Combination of amphetamine and PMA increased free radical formation by 360 ± 85%. In summary, our results showed that amphetamine may cause acute lung injury by overproduction of free radicals. Although amphetamine can activate PMN, the source of free radicals remains to be determined.

Dyspnea, Cough, and Fever for 7 Days in an Opiate Addict

A 21-year-old woman presented to the emergency department because of dyspnea, cough, and fever for 7 days. The patient had a history of intravenous heroin abuse. Radiographic and computed tomographic (CT) images are shown below (Figures ​(Figures11–4). Figure 1 Posteroanterior chest radiograph shows ill-defined areas of consolidation (arrows) in both lungs. Scattered, thin-walled cavities (arrowheads) are also seen throughout both lungs. Figure 4 CT image demonstrates a cavitary mass (arrow) with a large feeding vessel (arrowhead). These findings are diagnostic for this condition. For diagnosis and discussion, see the following page. DIAGNOSIS: Septic pulmonary emboli.

Effects of High-Dose Heroin versus Morphine in Intravenous Drug Users: A Randomised Double-Blind Crossover Study

The purpose of this study is to evaluate the effects of high doses of injected opiates as prescribed maintenance in intravenous drugs users. This was accomplished via a randomised double-blind study with crossover at an outpatient clinic in Bern, Switzerland. The subjects were 39 patients with a long history of intravenous opioid use and persistent abuse despite treatment; they were randomly allocated to two groups. Group A was started on controlled injection of graduated doses of morphine up to a satisfying individual dose and was then switched as a double blind to heroin at a randomly determined day between week three and four. Subsequently this group was given heroin for the remaining two to three weeks of the study. Group B was started on heroin and was then switched to morphine in the same manner. Equipotent solutions of 3% morphine and 2% heroin were administered. The main outcome measures were clinical observations, structural interviews and self report of subjective experiences to assess the effects of the drugs. In 16 cases, the study had to be discontinued owing to severe morphine-induced histamine reactions. Thirteen participants in Group B presented these adverse reactions on the day of the switch-over. Full data were thus only obtainable for 17 participants. Average daily doses were 491 mg for heroin and 597mg for morphine. The findings indicate that heroin significantly produced a lower grade of itching, flushing, urticaria and pain/nausea. A negative correlation between dose and euphoria was observed for both heroin and morphine. The authors concluded that as heroin produces fewer side effects it is the preferred highdose maintenance prescription to morphine. The perceived euphoric effects are limited in both substances.

Intravenous cocaine abuse: a rodent model for potential interactions with HIV proteins.

Intravenous cocaine abuse: a rodent model for potential interactions with HIV proteins.

Multinodular Focal Fatty Infiltration of the Liver in Acquired Porphyria Cutanea Tarda

A 42-year-old man presented with a bullous rash of the fingers associated with numerous small milia and malar hypertrichosis. He had a past history of intravenous heroin abuse and of chronic alcoholism. The diagnosis of acquired porphyria cutanea tarda was confirmed by an increased urinary excretion of uroporphyrin. The laboratory tests showed erythrocyte macrocytosis and abnormal serum liver tests (ALAT 131 UI/l; ASAT 73 UI/l; gamma glutamyl transferase, 233 UI/l). Hepatitis C infection with positive HCV-RNA and genotype 1b was found. Abdominal ultrasound showed parenchymal multiple hyperechoic nodules with a marked peripheral hyperechoic rim throughout the liver. These nodules measured about 1 cm and had no mass effect on vascular structures (Fig. 1). The CT-scan (Fig. 2) showed hypodense nodules with central enhancement after iodine contrast injection equivalent to that of the uninvolved liver. On T1-weighted sequences, the MRI scan showed a homogeneous liver, and after intravenous gadolinium injection it showed hyperintense nodular lesions. On T2-weighted sequences, it showed slight hyperintense nodular lesions with a hyperintense millimetric central zone. A percutaneous liver biopsy of a liver nodule was performed under sonographic control and showed mild chronically active hepatitis (METAVIR score A1F1) associated with hemosiderosis and macrovacuolar steatosis. This was consistent with the diagnosis of multinodular focal fatty infiltration of the liver as reported before (1). The patient was treated with phlebotomy and was advised to stop alcohol ingestion.

Morphine stimulates mesangial cell TNF-alpha and nitrite production.

Intravenous opiate abusers are susceptible to develop heroin and HIV-associated nephropathies; however, the role of opiates in the development of these kidney lesions is not clear. Patients with opiate addiction are prone to recurrent infections. The effect of morphine was studied on the generation of TNF-alpha with or without LPS (lipopolysaccharide) by cultured mouse mesangial cells. In addition, the effect of morphine was evaluated on mesangial cell nitrite production. To evaluate the role of opiate receptors, we studied the effect of naloxone and naltrexone on mesangial cell TNF-alpha and nitrite production. To determine the role of TNF-alpha on mesangial cell nitrite production, we examined the effect of anti-TNF-alpha antibody on morphine-induced nitrite production. Assay of TNF-alpha and nitrite production was carried by ELISA and Griess method respectively. Morphine alone did not enhance the generation of TNF-alpha by mesangial cells, however, an enhanced (P < 0.001) TNF-alpha production was observed when mesangial cells were first treated with morphine for 18 h and then activated further with LPS. Maximum release of TNF-alpha was seen at a concentration of 10(-12) M of morphine. Opiate receptor antagonists (naloxone and naltrexone) inhibited the effect of morphine. Morphine also amplified (P < 0.0002) the effect of LPS on mesangial cell nitrite production. Anti-TNF-alpha antibody attenuated morphine induced nitrite generation. We conclude that morphine stimulates the generation of TNF-infinity by LPS-activated mesangial cells. This effect of morphine seems to be opiate receptor mediated and has a downstream effect in the form of mesangial cell nitrite generation. The present in vitro study provides the basis for a hypothesis that morphine may be playing a role in the development of heroin and HIV-associated nephropathies.

Victims as victimizers: physical aggression by persons with a history of childhood abuse.

Substance abuse has been called the dominant characteristic of families involved in child abuse cases, but the frequency with which childhood victims become adult victimizers remains uncertain. To examine whether a history of childhood sexual or physical abuse is associated with becoming a victimizer (ie, abusing or assaulting others) as an adult. Interview data were collected from 439 persons in Providence, RI, from July 1997 through March 1998 who had a history of intravenous drug use. Victimizers were defined as adults who had ever physically abused or assaulted a family member or sexual partner (eg, kicked, hit, choked, shot, stabbed, burned, or held at gunpoint). We compared persons who had a history of victimizing others with those who did not have such a history by bivariate and multivariate analyses. Variables included demographic factors as well as a history of sexual or physical abuse before the age of 16 years. abuse was 51% for women and 31% for men. Seventeen percent of our subjects reported being victimizers. Among persons who reported being victims of either physical or sexual childhood abuse, 28% victimized others; among those who denied a history of childhood abuse, 10% victimized others. Two thirds of victimizers reported being intoxicated while assaulting others. When we used logistic regression to control for sex, having children, education, race, and history of incarceration, childhood abuse was significantly and independently associated with becoming a victimizer (odds ratio, 3.6; 95% confidence interval, 2.1-6.1). Large numbers of intravenous drug users, both men and women, have victimized family members or sexual partners. We confirm a high rate of childhood abuse among this population and demonstrate that among intravenous drug users past abuse is associated with becoming a victimizer as an adult. Primary care providers should be alert to this cycle of violence.

Pregnancy and substance abuse

The fetal consequences of drug abuse during pregnancy remain underestimated. Obstetrical complications of cigarette smoking include growth retardation, spontaneous abortion and sudden infant death syndrome; alcohol abuse leads to nutritional deficiencies and fetal alcohol syndrome. Heroin and cocaine consumption result in medical, nutritional and social neglect; cocaine and amphetamine cause hypertension, abruptio placentae; all three drugs of abuse cause preterm labor, with neonates being small for gestational age. Intravenous abuse also increases the risk of contracting infectious disease. The recommended treatment standard is to maintain pregnant, opioid-dependent women on synthetic opioids such as methadone, but newer substances like slow-release morphine and buprenorphine may also be beneficial. Treatment should be interdisciplinary and consider the high prevalence of substance dependent partners. Programmes should be initiated to identify women at risk and provide early treatment to improve the outcome for mother and child. Care must be provided in a supportive, proactive and non-judgemental fashion.

Waldenström's macroglobulinemia in young African-American adults.

We have identified five African-American patients with Waldenström's macroglobulinemia (WM) diagnosed at a young age (ages 35, 38, 38, 40, 51; 4 males, 1 female). All had a history of intravenous heroin abuse and four also used cocaine. Their manner of presentation and clinical course were typical. Three of three patients tested for the hepatitis C virus (HCV) were positive and three of three patients tested were HIV negative. The potential relationship between intravenous drug abuse and/or HCV to development of WM in this group of young patients is provocative, especially since a polyclonal increase in serum IgM is commonly seen in chronic intravenous heroin addicts. More recently, the contribution of HCV is being evaluated in lymphoproliferative disorders. Although WM is typically a disease of older people, it should also be considered in the differential in a young patient with a suggestive clinical picture.